Forensic psychology: Part 2: Chapter 4: Background

Psychological Intervention in Corrections

by Ralph C. Serin, Ph.D., C.Psych. ^{Footnote 1} 

Psychologists in correctional settings, by inclination and training, are committed to providing treatment services to offenders. The intensity and focus of their intervention varies considerably, in part due to differing theoretical perspectives and availability of resources. Several authors (Blackburn, 1993a; Watkins, 1992) have observed that the evolving role of psychologists in correctional institutions has had an impact on the proportion of time psychologists are able to assign to various duties. Provision of treatment is but one of these duties. The extent to which there evolves uni-dimensionality in role (i.e., over reliance on assessments) could impact on recruitment efforts, attrition rates of existing psychologists, and undermine therapeutic intervention with offenders. This is an issue to which psychologists and administrators must be sensitive in order to ensure that psychologists are able to maximally contribute to the needs of offenders and meet organizational requirements with a minimum of conflict in roles.

This brief chapter is by no means intended to be inclusive regarding the review of correctional treatment or treatment for different disorders. However, issues impacting on the provision of psychological intervention to offenders will be highlighted and suggestions proposed for future practice. Concerns regarding theoretical models, diagnosis, assessment and measurement of treat-ability and treatment gain will be discussed. Also, the distinction between treatment and programming will be considered. Finally, issues relating to treatment efficacy will be discussed as a framework against which to consider the investment of resources.

Treatment has been described as the application of therapeutic methods aimed at the prevention of reoffending which utilize some form of psychological change procedure (Blackburn, 1993a). This intervention is not limited to offending behaviour, but also addresses the offender's adjustment to imprisonment. This is a theme supported by Rice and Harris (1993) who express concern that organizational or theoretical perspectives not limit clinicians from intervening to improve the quality of offenders' daily lives while incarcerated. This dual responsibility to address criminogenic and mental health needs of offenders is reflected in the Commissioner's Directive on Psychological Services.

A description of the varied psychological interventions provided in correctional settings is presented by Andrews and Bonta (1993) and Blackburn (1993a, Chapter 13). Other summaries of problem-specific interventions are provided by Rice, Harris, Quinsey, & Cyr (1990) who consider traditional and forensic settings. Both summaries tend to highlight the emergence of cognitive-behavioural programs as the preferred strategy for intervention. Gendreau and Ross (1987) cogently summarize the correctional treatment literature and suggest effective intervention has been demonstrated, but that methodological rigor could be improved, notably in the area of measuring generalization effects. These reviews reflect the finding in the literature that traditional psychotherapeutic approaches have not been demonstrated to be as effective with offender populations (Andrews, Bonta & Hoge, 1990; Andrews, Zinger, Hoge, Bonta, Gendreau, & Cullen, 1990). Therapeutic rapport is important in skills-based interventions, yet it has a reduced emphasis. This distinction underscores the theoretical distinction of humanistic and psychodynamic approaches with cognitive-behavioural views. Nonetheless, the utility of a multifaceted intervention strategy that emphasizes clinical skills has been promoted for forensic settings (Blackburn, 1993b).

The heterogeneity of offenders suggests that a hierarchical treatment model may be helpful. Intensive intervention will likely include both group and individual work with treatment targets including both skills acquisition and intrapersonal development. Limiting treatment gain to only considerations of insight on one hand or recidivism on the other, however, would be inappropriate (Andrews, Bonta, & Hoge, 1990).

Psychotherapy outcome research in nonforensic settings has highlighted specific factors which contribute to successful therapy (Whiston & Sexton, 1993): the quality of the therapeutic relationship is crucial to positive outcome (Luborsky, Crits- Christoph, Mintz, & Auerbach, 1988); the selfullness of the clinician appears more relevant to outcome than theoretical orientation (Whiston & Sexton, 1993); session factors such as delay between referral and treatment initiation, duration of treatment, and initial compliance are also important (Whiston & Sexton, 1993). From the forensic literature emerges additional factors that impact on therapy outcome: matching the intensity of intervention to the risk level of the offender (i.e., responsiveness) is an important factor (Andrews, et al, 1990); style and mode of service should reflect offender characteristics (i.e., behavioural, cognitive-behavioural, skills based or social learning approaches). Only the more interpersonally and cognitively mature offenders may respond to more evocative, more relationship dependent styles of service. Targeting criminogenic need remains the primary focus for correctional treatment (Andrews et al, 1990; Gendreau and Ross, 1987).

Increasingly there is evidence that relying on diagnoses to facilitate treatment planning for forensic/correctional populations is of limited utility (Rice, Harris, Quinsey & Cyr, 1990; Rice & Harris, 1993; Rice, Harris, Quinsey, & Lang, in press). The prevalence rates of mental disorder are high in correctional samples (Hodgins (Sz.. Cote, 1990), yet it is unclear that offenders' mental disorders are necessarily criminogenic (Shapiro, 1991). The issue of co-morbidity becomes important, as does evidence of psychosis in offenders with Axis II (Personality Disorder) features. Assessment should yield a functional analysis to provide greater information for treatment planning and classification than simple diagnosis (Blackburn, 1993a). It may be, however, that for acutely disturbed offenders (i.e., psychotic), targeting factors purported to mediate criminality must be delayed until the mental disorder is controlled, where possible. Consistent with this view, Nezu and Nezu (1993) provide a conceptual model which emphasizes problem-solving as a strategy to the identification of treatment targets.

The absence of a standardized assessment strategy for the identification of treatment needs of offenders is a major shortcoming. Psychologists can play an important role in the development of a multi-method assessment protocol of criminogenic need. Further, standardized assessment of mental disorder and mental health concerns are required. These developments are essential if reliable and valid assessment of treatment targets are to occur. Additionally, theoretical and technological considerations need to be applied to the issue of measuring treatment gain. Distinguishing between treatment gain, maintenance of said gain, and generalization of treatment is an important, albeit underdeveloped, task.

While good assessment is fundamental to effective intervention (Blackburn, 1993a), many psychologists have raised concerns regarding the increasing practice of assessing offenders without providing treatment. In a similar vein, if assessments are static, they contribute little to the question of dynamic risk management. It is important for psychologists to clarify their roles in these activities. Comprehensive assessment is vital to the identification of treatment targets (Nezu & Nezu, 1993), but this is not unique to psychological practice in corrections. Nonetheless, the techniques for assessing criminogenic need should be multi-faceted and require further development. Such development could extend the work in the treatment of addictions and sexual offenders regarding the identification of high risk situations for re-offense (Pithers, 1990).

The treatment of disorders such as depression and anxiety have been a staple for psychologists. Similarly, intervention in the areas of substance abuse, social skills and anger control has been the purview of psychologists independent of their setting. A recent review of these treatment targets (Rice et al, 1990) suggests they may not directly relate to offenders presenting concerns or criminogenic factors. Several studies have attempted to investigate those factors which offenders report are related to their criminality or will be concerns upon release (Andrews, 1982; Pithers, 1990; Rice & Harris, 1993; Zamble & Quinsey, 1991). Impulsivity, anger, social alienation and financial pressure are reported by Zamble & Quinsey (1991) from a study of offenders' self reported risk factors. Pithers et al (1988) report social alienation, anger and substance abuse to be important precursors to sexual offending, as rated by clinicians. These treatment targets and additional criminogenic factors should then represent the primary areas for intervention with offenders. Specific targets in specialized areas will also be required: sexual arousal in sexual offenders; arousal and cognitive schema in violent offenders; instrumentality or use of violence in abusive men.

Summarizing problem-frequency surveys (Rice et al, 1990), comorbidity of diagnoses in correctional samples (Hodgins & Cote, 1992), and offender self reports, it appears that substance abuse, emotional dysphoria, and antisocial attitudes are important treatment targets for the reduction of risk of reoffense. Community support, both employment and familial, and constructive use of leisure time are also important (Hubert & Hundleby, 1992). It is noteworthy that these areas are reflected in the Community Risk Needs Management Scale (Motiuk & Brown, 1993), although increased specificity may well facilitate an improvement in the assessment of treatment gain.

Traditionally, psychologists have provided individual therapy. However, fiscal limitations and demands for other services, notably assessments, have dictated a rise in the popularity of group treatment. In some circumstances (i.e., skills acquisition), group presentation is not only cost-effective, but may enhance learning (Goldstein & Keller, 1987). Some settings match the offender to the mode of presentation, such that low IQ offenders or those who are disruptive in groups are provided individual sessions.

The issue of matching offenders for specific groups does not appear common practice in corrections. For instance, only rarely are heterogeneous groups of offenders differentiated for treatment participation. Sexual offenders are considered heterogeneous regarding antecedents, risk factors and treatment needs. Nonetheless, groups often include rapists, incest offenders and extra familial pedophiles, unless the treatment setting restricts admission for sampling or operations concerns. When selection does occur, there appear to be clinical advantages (Marshall, Jones, Ward, Johnston, & Barbaree, 1991). An important question is whether improved selection of offenders for intervention facilitates a better understanding regarding responsivity factors. That is, which offenders respond best to which aspects of intervention. This issue applies equally to violent offenders. Blackburn (1993a) has noted that typically "anger control" programs are provided without regard to whether the offender is under- or over-controlled, has low or high arousal, has a persistent or infrequent history of violence, is nonpsychopathic or psychopathic, and is instrumental or affective in his use of violence. Intervention which considers such factors might demonstrate improved efficacy.

As noted previously for community settings, the theoretical orientation is less important than the skill level of the clinician (Whiston & Sexton, 1993). Some characteristics of offenders suggest that some models of intervention are more likely to be effective, i.e., cognitive-behavioural (Gendreau & Ross, 1987). Increasingly, relapse prevention is being embraced as a conceptual framework for intervention. This viewpoint has been applied extensively and with considerable success to the areas of addictions and sexual offenders. It is less clear that an "offense cycle' occurs for all offenders, or that identification of risk factors (proximal or distal) improves generalization effects, thereby reducing the risk level of the offender. Nonetheless, this model facilitates the continuum of intervention, from the institution to the community. Presumably, treatment intensity varies along the setting continuum. It is clear is that a theoretical model is critical for the development of working hypotheses regarding treatment needs and methods employed to evaluate treatment gain.

The development of a model that incorporates dynamic factors will permit clinicians to reflect changes in risk according to gains in treatment programs. Treatment targets therefore need to be fluid, although distal factors, i.e., developmental, also require review.

Consistent with professional standards of practice, treatment reports (progress and summary) must comment of the frequency of contact, the degree to which treatment objectives were met and future treatment needs. Where possible, this would be related to risk management strategies. These requirements may appear to exceed the release of information guidelines understood by psychologists. Participation in treatment must be voluntary, however, the consequences of non participation must be presented to the offender to ensure (s)he is informed. The limits of confidentiality as reflected in the Commissioner's Directive and the Corrections and Conditional Release Act must be explicitly explained to the offender. This might be best accomplished by a written statement to be signed by the offender prior to assessment and/or treatment.

If a clinician has invested considerable time into the treatment process with an offender, the potential need for an independent assessment is increased. The clinician might appropriately provide risk management strategies based on their intimate knowledge of risk factors for the particular offender. They may, however, exaggerate the gains made by the offender in treatment, particularly in the absence of objective criteria for treatment success. This area requires judicious review on a case-by-case basis. Clinicians might avail themselves of consultations with knowledgeable colleagues or utilize actuarial models in an effort to ground their assessments.

Implicit in this review has been the expectation that a primary function of intervention is to reduce the risk of re-offense by addressing those factors which increase an offender's likelihood of recommitting crimes. In a simplistic form, this represents providing treatment regarding addictions to an offender whose criminogenic need is substance abuse. The intensity of intervention should match the degree of need and the risk level of the offender. Higher risk offenders should receive more intensive intervention (Andrews et al, 1990). For instance, few would argue that educational programmes are sufficient for offenders with persistent problem behaviours, be they addictions or violence. However, provision of treatment services often requires a multi-faceted strategy, with a clear functional analysis. Determining the interaction among treatment needs, the priority for intervention and the ordering of different treatment efforts, are also complex tasks.

The issue of treatability may be relevant to treatment outcome, but it has proved to be an elusive construct (Quinsey & Maguire, 1983; Rogers & Webster, 1989). Importantly, Quinsey (1988) emphasized that improvements in this area may be more useful than expanding risk prediction efforts. Heilbrun, Bennett, Evans, Offutt, Reiff and White (1988) review factors important in considering the assessment of treatability. These, however, have not been operationalized and there is limited consensus regarding who is treatable. For some therapists, it may simply represent likeability, an awkward concept when dealing with violent offenders. At one level, however, this construct has been incorporated into risk assessment strategies when clinicians assess compliance for ongoing intervention/medication and performance in past treatment (Steadman, Monahan, Robbins, Applebaum, Grisso, Klassen, Mulvey, & Roth, 1993).

Optimally, comprehensive assessment and provision of treatment affords the clinician a better understanding of the circumstances of the offender's criminality, his (her) gains in treatment, and key areas for further intervention. These translate into an offender-specific risk management strategy. This clearly requires the full participation of the offender in a kind of working alliance (Gelso & Carter, 1985). Given the population, this will require good clinical skills and open communication regarding the purpose of intervention. Not all offenders will be amenable to such a proposal. At a minimum, poor motivation regarding treatment might be considered a exacerbating factor in terms of prognosis. Another concern is that offenders will simply participate in groups for expedient rewards (i.e., increased probability of release). Both group and individual treatment programs require clearly articulated objectives in an effort to ensure offenders appreciate that treatment is a "process, not an event" (Sechrest, White, & Brown, 1979).

The following principles appear to best characterize good correctional treatment:

• cognitive-behavioural;
• social learning, modelling anti-criminal behaviour and attitudes;
• graduated practice of new skills, including role playing;
• concrete suggestion instead of abstract concepts;
• multi-faceted interventions with theoretical underpinnings;
• the use of specific selection criteria;
• the use of pre and post measures;
• where possible, methodological rigour by using control groups (random or waiting list); and
• providing a continuum of intervention at different levels of intensity, matched to offenders' needs, and at all stages of the sentence.

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